K Kerbl's scientific contributionswhile working at Universidade Federal de São Paulo (São Paulo, Brazil)and other institutions
- [Show abstract] ABSTRACT: Since 1877, 42 cases of non-Hodgkin lymphoma of the prostate have been reported in the medical literature, whereby the occurrence of a primary process could only be assumed in a very few of these. We report a case of primary non-Hodgkin lymphoma of the prostate, including a review of literature, and point out the difficulties involved in diagnosing such cases.
- [Show abstract] ABSTRACT: The case of a 34-year-old male is reported, who was transferred to the Regional Medical Center in Wels in an uraemic state and subsequently was diagnosed as having prune belly syndrome. Surprisingly, his past history revealed no serious health problems until 6 months before admission. Furthermore, some interesting aspects of the prune belly syndrome such as the controversial views regarding pathogenesis and treatment are briefly discussed.
- [Show abstract] ABSTRACT: Six patients underwent laparoscopic nephroureterectomy as treatment for upper tract transitional cell cancer. Mean operative time was 7.29 h and mean postoperative hospital stay was 4.6 days. In all but 1 case, the cuff of the bladder was obtained using a laparoscopic 12-mm GIA tissue stapler. With follow-up out to 16 months, we have not encountered any complications due to the transvesical staples, such as urine extravasation, stone formation, urinary tract infection or abscess formation. Our initial clinical data indicate that laparoscopic nephroureterectomy, albeit a lengthy procedure, can be performed with minimal morbidity and a short post-operative hospital stay.
- [Show abstract] ABSTRACT: Laparoscopic nephropexy was performed in a 25-year-old woman with intractable pain and a palpable pelvic mass associated with right nephroptosis for more than 1 year. Evaluation by a supine and an erect intravenous urogram (IVU) revealed right renal descent of three vertebral bodies with mild hydronephrosis. Laparoscopic transperitoneal nephropexy was performed in a 2 and a half hour procedure. The patient stayed in the hospital 2 days postoperatively and returned to full activities 3 weeks later. At 2 months postoperatively, she is asymptomatic. An upright IVU2 months postoperatively revealed renal descent of only one vertebral body and no hydronephrosis. This is the first report to our knowledge of a successful laparoscopic nephropexy.
- [Show abstract] ABSTRACT: Laparoscopic nephrectomy using an entirely retroperitoneal approach was performed in six anesthetized female pigs. In each animal, the kidney was localized using fluoroscopy, following which the retroperitoneum was insufflated with CO2. Subsequently, a retroperitoneal laparoscopic nephrectomy was performed in a 48-year-old man with a chronically obstructed, nonfunctioning kidney. Although the retroperitoneal approach provides excellent exposure for the dissection of the renal hilum, anatomic factors in the human limit port placement and organ entrapment and increase the risk for development of a pneumothorax.
- [Show abstract] ABSTRACT: Evaluation of the role of staples, clips, and sutures for laparoscopic ligation of the renal artery revealed that occluding the renal artery with three, 9 mm titanium clips is as secure as occluding the renal artery with standard 2-0 and 0-silk ligatures. However, a triple staggered line of 2.5 mm staples placed across the renal artery was not as secure as either clips or silk sutures. The authors also studied eight female farm pigs who underwent laparoscopic nephroureterectomy with en masse stapled occlusion of the renal hilum. In one animal, an arteriovenous fistula was documented 6 months postoperatively. Currently, when laparoscopically occluding the renal hilum, the authors recommend a thorough dissection of the renal artery and renal vein; each should then be separately occluded so that three individually placed titanium clips remain on the stump of the renal artery and on the renal vein.
- [Show abstract] ABSTRACT: Laparoscopic urology has only recently become a technique of interest to many urologists. In this article, an overview of the basics common to all laparoscopic procedures is presented. In addition, the current applications of laparoscopy to urology are discussed.
- [Show abstract] ABSTRACT: With a combination of cystoscopic and laparoscopic techniques, 3 patients underwent total ureterectomy for urothelial cancer without complication. Of the patients 2 underwent concomitant laparoscopic nephrectomy. Mean operating time was 8.2 hours for the laparoscopic surgery and mean hospital stay was 6 days. In 2 patients the ureter was removed intact, while in 1 it was morcellated along with the kidney before removal. In each case the bladder was closed with a 12 mm. GIA laparoscopic stapling device. After 3 to 9 months of followup no patient had recurrent disease or bladder stones on the staple line.
- [Show abstract] ABSTRACT: We report our experience with closure of the bladder during laparoscopic nephroureterectomy by using a gastrointestinal anastomosis type stapling device designed to deliver 6, 3 cm. rows of 3.5 mm. titanium staples via a 12 mm. trocar. We initially used this stapling device to secure a cuff of bladder in 8 female pigs undergoing laparoscopic nephroureterectomy. Followup in these animals was completed 2 to 6 months postoperatively. Then, 3 patients underwent laparoscopic ureterectomy using the laparoscopic stapler to transect and secure the ureter along with a cuff of bladder. In neither the laboratory nor the clinical situation were any complications encountered due to the transvesical staples (for example extravasation, stone formation, urinary tract infection or abscess formation). Our preliminary results indicate that titanium staples may be an effective method to provide rapid and secure closure of the bladder in patients undergoing either laparoscopic nephroureterectomy or laparoscopic ureterectomy.
- [Show abstract] ABSTRACT: Urologic applications of laparoscopy have increased exponentially in the past few years, and newer techniques continue to be described. This article considers the latest advances in the field and attempts to place laparoscopy in proper perspective in urologic therapy. From modest diagnostic maneuvers, urologic laparoscopy has progressed to ablation of large solid organs and complex reconstructive procedures. Reproducible clinical success has been achieved in localization of undescended testicles, varicocelectomy, dissection of pelvic lymph nodes, drainage of lymphoceles, and nephrectomy. Clinical reports on use of this technique for orchiectomy, ureterolysis, nephropexy, partial nephrectomy, nephroureterectomy, bladder diverticulectomy, dissection of retroperitoneal lymph nodes, and ileal conduit urinary diversion have been published. Exciting and rapid development of more advanced techniques is under way in the laboratory. Even at this early stage, when urologic applications of minimally invasive surgery are still being defined, it is likely that laparoscopy will have a lasting impact on the practice of urology.
- [Show abstract] ABSTRACT: In an effort to further evaluate the potential application of laparoscopy to urologic surgery, we explored the feasibility of using this minimally invasive approach for performing a partial nephrectomy. Nine female pigs underwent laparoscopic partial nephrectomy (LPN) utilizing a plastic cable tie (15 mm. x 4 mm. x 1 mm.) to achieve renal ischemia and an Argon Beam Coagulator probe (ABC) (Birtcher Medical Systems) to fulgurate the transected surface. Six weeks after LPN, 6 pigs underwent creatinine clearance, renin level, arteriography, BP samples and were then killed. The renal remnants were weighed and sectioned for histological studies. These studies revealed excellent function of the renal remnant, no AV fistula, and no evidence of renovascular hypertension. LPN is a feasible, repeatable procedure in the pig. Control of the renal hilum, transient parenchymal compression with a plastic cable, and use of the argon beam coagulator are key elements in performing this procedure.
- [Show abstract] ABSTRACT: The operative morbidity and convalescence of our initial 30 patients who underwent laparoscopic pelvic lymph node dissections were compared to those of 16 patients who underwent open surgical pelvic lymph node dissections performed at our institution for staging purposes between 1990 and 1992. The average time for laparoscopic pelvic lymph node dissection (199.4 minutes) was nearly twice that of surgical pelvic lymph node dissection (102.4 minutes). However, the blood loss in the former group was significantly less. Oral intake occurred after a mean of 0.63 days in the laparoscopic pelvic lymph node dissection group compared to 2.87 days in the surgical group. Also, laparoscopic pelvic lymph node dissection was superior to surgical pelvic lymph node dissection in terms of average postoperative analgesic use (1.55 versus 47 mg. morphine sulfate), average hospital stay (1.7 versus 5.37 days), average return to normal daily activities (4.94 versus 42.9 days) and interval to full recovery (10.8 versus 65.5 days). However, the incidence of significant complications in the laparoscopic pelvic lymph node dissection group was 13%, with no complications seen in the surgical group. Interestingly, all significant problems in the bilateral laparoscopic pelvic lymph node dissection patients were confined to our initial 12 patients, indicating the steepness of the laparoscopic learning curve.
Article: Laparoscopic renal surgery[Show abstract] ABSTRACT: Despite all the recent developments in laparoscopic renal surgery, it has to be kept in mind that although only small incisions are made, laparoscopy is still surgery. Therefore, the technical background as well as the surgeons' skills must ensure that any laparoscopic procedure can be quickly converted into an open surgical procedure, if complications (such as bleeding or injury to the viscera) or unexpected difficulties (inability to establish a pneumoperitoneum) should occur. Also, as with any new procedure, the value of each new laparoscopic technique can only be determined by direct and critical comparison to its current open incisional surgical counterpart. In order to progress from a heralded "fad" to a medically accepted "fixture", each laparoscopic innovation must provide the patient with a less morbid, yet equally efficacious alternative to open surgery. Stated more simply, the query remains: "It's new but is it better?"
- [Show abstract] ABSTRACT: Laparoscopic approaches to adrenalectomy have been limited by the retroperitoneal (RP) location of the adrenal glands and their relative inaccessibility transabdominally. We developed a technique for endoscopic adrenalectomy in a domestic swine model using insufflation of the RP space with CO2 and retroperitoneoscopy. The technique for retroperitoneal endoscopic adrenalectomy was first developed in an acute study of three animals. A chronic survival study was then undertaken in six pigs. Unilateral right (n = 3) or left (n = 3) adrenalectomy was performed. Mean RP insufflation time was 14.5 min (range, 7-30 min), and mean dissection time after insufflation was 100 min (range, 80-120 min). Two additional animals died under anesthesia after RP insufflation and placement of the trocars for retroperitoneoscopy but before dissection of the adrenal gland. One death was unexplained at autopsy. The other death was associated with a right-sided pneumothorax attributable to penetration of the diaphragm by a trocar. The remaining six pigs recovered uneventfully from the procedure. Autopsies performed 37 to 51 days postoperatively showed minimal scarring of the adrenalectomy bed. The results suggest that posterior adrenalectomy using RP CO2 insufflation and direct retroperitoneoscopy is potentially applicable to the treatment of small adrenal lesions in humans.
- [Show abstract] ABSTRACT: In this manuscript we describe our initial experience with 22 patients who underwent laparoscopic nephrectomy at our institution. Of the 22 patients, 16 patients had benign disease, and 6 patients had malignant disease. Of the 6 patients with malignancy, 3 patients underwent laparoscopic nephroureterectomy for transitional cell cancer of the upper urinary tract. In 21 patients, a transabdominal approach was utilized, whereas 1 patient underwent laparoscopic nephrectomy using an entirely retroperitoneal approach. Laparoscopic nephrectomy showed lengthy operative times, but resulted in reduced postoperative discomfort, shortened hospital stay, and rapid convalescence. As laparoscopic nephrectomy has been performed with reproducible success by various other groups worldwide, further refinements in surgical technique, paired with advances in laparoscopic instruments designed for stapling and suturing, will most likely result in an increasing application of the principles of laparoscopy to diseases of the kidney, renal pelvis and ureter.
- [Show abstract] ABSTRACT: A case of spontaneous regression of an osseous metastasis in renal cell carcinoma is presented. The extreme rarity of this phenomenon, especially in this location, is pointed out, as only three other cases have been published so far.
- [Show abstract] ABSTRACT: Ureteral strictures were created in 18 minipigs. Six weeks after stricture inducement, endourologic incision with a balloon cutting device was performed and a 7 F internal polyurethane stent was placed. After this step, 14 pigs remained in the study and were randomized into three different groups depending upon the time when the stent was removed: 1, 3 or 6 weeks. Twelve weeks after stricture incision, the pigs were killed, the status of the incised ureteral segment was evaluated histologically, and a healing score was determined. There were no statistically significant overall differences among the mean values of the overall healing score throughout the three different groups. However, when the one-week and the six-week groups (p < .05) were compared with respect to strictures requiring more than one incision due to stricture length greater than 2 centimeters, a more favorable outcome occurred in the 1 week group. Based on these findings it may be reasonable to remove ureteral stents as early as 1 week after endoureterotomy and endopyelotomy.
- [Show abstract] ABSTRACT: Laparoscopic nephrectomy has been shown to be an effective minimally invasive technique for treating benign renal disease requiring surgical excision. However, its application to approach renal malignancy has been limited. Herein, we report on 8 patients with renal tumor who underwent a laparoscopic nephrectomy. All kidneys were removed within Gerota's fascia, and in 3 patients with upper pole tumors, the adrenal gland was also removed en bloc. With limited follow-up of seven to thirty-five months (mean 14 months), there has been no clinical or radiographic evidence of tumor recurrence. We believe that laparoscopic radical nephrectomy with strict adherence to oncologic surgical principles is a practical, less invasive alternative in select patients with renal tumors.
- [Show abstract] ABSTRACT: Ureteroscopy for treatment of upper tract transitional cell cancer is complicated by the need for subsequent outpatient, anesthesia-based, surveillance ureteroscopy to detect recurrent tumors. We report on 2 patients with ureteroscopically treated renal pelvic transitional cell carcinoma in whom the ureteral tunnel was incised. By rendering the ureterovesical junction incompetent, we created a widely patent refluxing ureteral orifice. During the last 2 years we have been able to perform repeatedly office-based flexible surveillance ureteroscopy without fluoroscopy and without oral or parenteral analgesics in both patients.